Provider Demographics
NPI:1942309737
Name:MOUSAM VALLEY PODIATRY, P.A.
Entity Type:Organization
Organization Name:MOUSAM VALLEY PODIATRY, P.A.
Other - Org Name:ROCHESTER FOOT & ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:W
Authorized Official - Last Name:GERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:603-994-7633
Mailing Address - Street 1:PO BOX 736
Mailing Address - Street 2:
Mailing Address - City:SPRINGVALE
Mailing Address - State:ME
Mailing Address - Zip Code:04083-0736
Mailing Address - Country:US
Mailing Address - Phone:603-994-7633
Mailing Address - Fax:603-994-7648
Practice Address - Street 1:21 WHITEHALL RD
Practice Address - Street 2:SUITE #302
Practice Address - City:ROCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03867-3236
Practice Address - Country:US
Practice Address - Phone:603-994-7633
Practice Address - Fax:603-994-7648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0193213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1942309737OtherGROUP NPI #
ME1760487441OtherINDIVIDUAL NPI #
ME037709OtherANTHEM
NH1942309737OtherNPI GROUP
ME195460000Medicaid
NH1760487441OtherINDIVIDUAL NPI
NH3089587Medicaid
ME1942309737OtherGROUP NPI #
ME1760487441OtherINDIVIDUAL NPI #
NH3089587Medicaid
ME195460000Medicaid